J Immigrant Minority Health DOI 10.1007/s10903-014-0035-6
ORIGINAL PAPER
The Description of Health Among Iraqi Refugee Women in the United States Khlood F. Salman • Lenore K. Resick
Springer Science+Business Media New York 2014
Abstract The purpose of this study was to understand the description of health among Iraqi women refugees, their health status, and health experiences during resettlement in the United States. Twelve women, ages 21–67 years old, who resettled in the United States during or after 2003 where interviewed. The women described health as a gift determined by God, the ability to function, the absence of physical symptoms, and the need to feel safe and secure in the context of resettlement. Although the Iraqi women valued health, during the resettlement process, seeking safety and feeling secure were the foremost priorities. Findings revealed that this is a vulnerable population which has experienced the violence of war and, as a result, have unique physical, mental, economic, and social concerns related to health. Implications are for a multidisciplinary approach to best meet the unique individual health needs of this vulnerable population. Keywords Health Iraqi refugee Women Vulnerable populations War
Introduction Since 2003, more than 4.5 million Iraqis have fled their homeland because of violence in Iraq. Some were displaced internally, and others fled to neighboring countries such as Jordan, Syria, and Egypt. Estimates are that at least 2,000 people became homeless daily from 2003 to 2007, which is reported to be the largest Middle East refugee K. F. Salman (&) L. K. Resick Duquesne University School of Nursing, 600 Forbes Avenue, Pittsburgh, PA 15282, USA e-mail: [email protected]
crisis in history [1]. In the United States (US), the number of Iraqi refugees seeking resettlement also has increased significantly since 2007. Based on the data reported by the U.S. Citizenship and Immigration Services (2013), the number of Iraqi refugees admitted to the United States was increased from 1,608 in 2007 to 18,016 in 2010 [2]. Approximately 52,285 Iraqis with refugee status have admitted to the United States between 2007 and 2010 [2]. The Canadian Research Institute for the Advancement of Women (CRIAW) reported that on average 75–80 % of displaced people in any crisis are women and children [3]. According to the Iraqi Red Crescent Society, more than 83 % of Iraqi refugees were women and children [4]. The term refugee refers to ‘‘a person who is unable or unwilling to return to their country of nationality because of persecution or a well-founded fear of persecution on account of race, religion, nationality, political opinions, or membership in a particular group’’ [5]. Refugee women have been identified as a vulnerable population at risk for physical and mental illnesses [6]. This study evolved out of our encounters with Iraqi refugee Muslim women who experienced critical life situations (e.g. wars and violence), who may have descriptions and perspectives of the concept of health that are different from the concept and perceptions of health outside of their homeland. Many of the Muslim women we encountered expressed reservations when coming to the United States related to religion and culture. These reservations include the traditional Islamic attire which makes them visually different than other women, language barriers, cultural norms and values. Understanding the description of health by the women from their own worldview is a fundamental step to ensure mutual understanding and effective communication which are the means for delivering culturally competent care.
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Background
Recruitment and Data Collection
Health care providers, strive constantly to achieve their clients’ ultimate goal of ‘‘being healthy.’’ The concept of health is evolving with multidimensional descriptions. There is no one standard description of the concept of health. Health has been described as, ‘‘a state of well-being in which a person is able to use purposeful, adaptive responses and processes physically, emotionally, spiritually and socially’’ [7] (p. 53). Other scholars have described health as, ‘‘actualization of inherent and acquired human potential through goal-directed behavior, competent selfcare, and satisfying relationship with others’’ [8] (p. 22). Attaining high levels of health has been described as a state when the person is ‘‘free of discomfort and pain that permits one to function effectively within the environment’’ [8] (p. 19). The meaning of health has been described in terms of stability and balance—the ability to adapt to the environment and to adjust to different internal or external stresses [9, 10]. The literature revealed limited studies related to the description of health by immigrant and refugee populations. Although studies have addressed the health status and meaning of health among Russian refugee women [11, 12] and Afghanistan refugee women living in the United States [13], no single study focused on the description of health and the health status of Muslim Iraqi women refugees after the Iraqi war crisis in 2003 within the context of resettlement. The purpose of this study was to answer the following questions: (1) How do Iraqi refugee women describe the concept of health and ‘‘being healthy?’’; (2) How do Iraqi refugee women describe their own health status within the context of resettlement?; (3) How do Iraqi refugee women describe their health experiences within the context of resettlement?
The study was conducted in a city located in the eastern part of the United States. The city was chosen because of the large number of Iraqi refugees who have recently settled in this area. Data from the Office of Refugee resettlement reported that the number of Iraqi refugees who arrived in the state where this study took place had increased more than ten times from 40 in 2003 to 479 in 2010 [15]. In the specific region of this study, most of the Iraqi refugees were self-identified as Muslim women. The study was approved by the Institutional Review Board (IRB) for protection of human subjects. Study participants were recruited through flyers in both English and the Arabic languages. The flyers were posted in the local Islamic Center and two agencies serving refugee populations. Women were also recruited through word of mouth and key informants. Key informants were immigrant Muslim women from the Middle East, who had been in the United States for many years, and are known for their volunteer services to the Muslim community at large. The participants were selected using purposive sampling and snowballing technique [16]. The study participants were asked to identify and refer women who met the criteria for the study. The participants were recruited from a potential pool of approximately 40 women. Twelve women participated in this study. Once we determined the eligible study participants, a time and place were scheduled for the initial meeting at the convenience of the participant. All interviews were conducted in a natural setting in the women’s homes. Study participants were self-identified as Iraqi women refugees who resettled in the United States during or after 2003, were 21 years or older, spoke either Arabic and/or English, were able, and open to discuss elements of their health experiences within the context of being a refugee. Data Collection
Method A qualitative descriptive inquiry approach was used to collect data. Descriptive research is described as ‘‘the exploration and description of phenomena in a real-life situation. It provides an accurate account of characteristics of particular individuals, situations or groups’’ [14] (p. 34). The purpose of the descriptive design is to describe the phenomenon in a holistic way, as it is experienced. We sought to study the description of the concept of health, the health status as understood by the Iraqi women refugees, and their experiences within the context of the resettlement (i.e., real life situation). The descriptive qualitative design was consistent with the purpose of this study and the research questions.
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The interviews were completed within a 5-month period (June 2010 to November 2010). When data collection began, we repeated the explanation of the study and asked the participant to read the informed consent document; the participant received a copy of the English or the Arabic consent document depending on their preference. We asked permission to tape the interview. Once permission was given, we asked questions about demographic data. The audiotaped interview directly followed the collection of demographic data. The participants were asked to describe the concept of health, what health meant to them, their health status and experiences within the context of resettlement. Probe questions were included to initiate responses and to assist in clarifying meanings. These questions
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included: ‘‘Can you tell me more about that?’’ and ‘‘Can you give me an example?’’ The interview ended with debriefing questions such as, ‘‘Is there anything else about health and resettlement that you think I should know?’’ and ‘‘I will be interviewing other women from Iraq about their refugee experience and health. What has this interview been like for you?’’ These were asked to allow study participants to discuss issues of importance that may not have been elicited through the original interview questions proposed in the study. Although it was anticipated that it would take 60–90 minutes to complete the interviews, no time limit was imposed. Most interviews took about an hour to complete. Data were collected until ‘‘saturation’’ was reached [16]. Saturation was reached when no new data emerged from the analysis of the transcriptions. Field notes were kept to describe the natural environment, in which the interviews took place, document the content of informal conversations that occurred spontaneously after the taped sessions were completed and to provide a context of the verbal and emotional expressions during the interviews. A second follow-up interview was scheduled approximately 2–3 weeks following the initial interview to clarify responses. However, two participants were unable to complete a second interview; one woman made a family emergency trip to Jordan and the other one left the United States due to the challenges experienced in learning the language and feeling overwhelmed throughout the resettlement process. To ensure accuracy of the initial analysis, we verified the interpretations of transcripts from the first interview during the second interview. Participants specifically were asked if they had anything to add to the points discussed and whether there was anything they would like to have omitted from the analysis. Changes, additions, and clarifications in regard to the researchers’ interpretation were discussed. The second interview continued until the informants agreed that the descriptions of their experiences had been interpreted as they had intended. The second interviews took approximately 45 minutes to an hour each to complete. Data Analysis An experienced transcriber, who signed a confidentiality statement, transcribed the audiotape interviews verbatim. The tapes in Arabic were translated to English and then translated back to Arabic by another translator to ensure conceptual equivalency. Then, to ensure accuracy, two different Arabic-speaking individuals translated the transcript back to English. We independently reviewed each transcript, assigned themes that reflected the words of the study participants as closely as possible, and clustered common themes [17]. Then we compared the independent coding; generally,
there was agreement between our independent coding. The themes that were identified and agreed upon served as the discussion topics during the second interview. We read aloud the identified themes and discussed them with participants to check the degree of participant and investigator agreement. Generally there was agreement. During the few times there was not agreement, the inconsistency was discussed until consensus was reached. The rigor and trustworthiness of the research process were ensured by addressing ‘‘credibility, confirmability, dependability, transferability, and authenticity’’ [18] (p. 544). Credibility was achieved by spending adequate time with the informants to identify repeated or reappearing patterns, and allowing adequate time for the participants to express their personal experiences and verbalize concerns. To avoid bias, we conducted the interviews together, and bracketed our assumptions and preconceived knowledge related to the interview questions by recording our responses to the interview questions before meeting with the study participants [19]. We completed data analysis independent of each other, and then compared results. Probe questions were also included to initiate responses and to assist in clarifying meanings. Transferability was addressed by ensuring that all the participants were self-identified as Iraqi women refugees, who have been the United States since 2003 and representative of this population. Dependability (or the consistency of findings) was achieved by collecting data until saturation was reached. All interviews were audio taped to enable us to listen multiple times for rechecking and ensuring consistency of interpretations. Confirmability was attended to by scheduling a second interview with the participants to confirm the interpretations of their experiences and description of the study phenomena. We also analyzed the data separately, compared the results, and discussed differences and similarities of the themes. Authenticity was achieved as we ensured the trustworthiness of the data. All interviews were conducted by the two of us. The principal investigator is native to the language and culture, and has been actively involved with the Iraqi refugee community for the past several years. We also hired a professional transcriber, who is fluent in English and Arabic languages to ensure additional accuracy. All audio-taped interviews were in the native language of the participants translated to English and back to Arabic and then to English.
Findings Demographics The average age of the 12 refugee women who participated in the study was 43 years of age with an age range from 21
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to 67 years. The length of stay in the United States ranged from 2 months to 4 years. Educational levels of the study participants varied from completion of middle school to a college degree. All women except for one (who was single) were married and lived with their spouses. The married women had two to six children ranging in age from 5 to 35 years of age.
Health as Experiencing No Physical Symptoms Women also described feeling healthy as having no visible disease and being healthy when they had no physical symptoms. For example, a participant stated that she was healthy saying, ‘‘I never went to the doctor. When I go to doctors, they are surprised at how well I am.’’ Health as Being Safe and Secure
Description of the Concept of Health Data analysis resulted in several themes related to the description of health. These included health as a highly valued treasure; a gift determined by God; the ability to function inside and outside the home in expected roles (e.g., wife, mother, sister, and student); experiencing no physical symptoms; and being safe and secure. Health as a Highly Valued Treasure One participant summed up the responses from the other participants, ‘‘Health means everything to me; without it I cannot be happy. Health is the most important thing… we consider it as the crown on the head of healthy people…it is like a treasure.’’
Health as a Gift Determined by God All the women expressed a strong belief in health as determined by God, and used prayers to help them in all aspects of life. ‘‘We say everything comes from God, you know, If God wants something wrong with us, nobody can stop it.’’ Another participant shared her experience of being diagnosed with a suspicious lesion in the breast after a mammogram screening. She mentioned that ‘‘she asked Allah (God) to help her in her prayers; days and nights, because she did not want that disease (cancer)’’. After she went for her second mammogram, the physician informed her that it was negative. Health as the ability to function inside and outside the home in expected roles. One participant’s words summed up the theme of health as the ability to function. ‘‘It means everything to me; health is involved in the way you take care of your family, how you live your life. If you’re healthy, you can fulfill all of the duties outside and inside the house.’’ Another stated, ‘‘I was happy, active, I didn’t have worries…Whenever I was healthy, I could go out, take care of the house, my kids. My movement in the house becomes easier. My duties within the house can be and are completed…uhhh… if my neighbors need help, I can help them also.’’ According to another participant, ‘‘If one doesn’t have good health….life stops.’’
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Although health was not a major focus for the women during the resettlement process, they all valued health, and considered safety and security as important aspects in the description of the health and ‘‘being healthy’’ status. A participant expressed that being unsafe with her family made her sick, ‘‘… we just wanted to be safe because our lives (both her husband’s and hers), my kid’s life, was in danger at that time…I was sick!’’ She was worried about her status, saying, ‘‘I hope that we will all be safe and secure… not worry about tomorrow because that’s what makes me sick…uhm, because, you know, we are not sure what will happen tomorrow…’’ Other participants also mentioned that safety was their highest priority. This is obviously due to the fact that many women and children were at risk for kidnapping, murder, and exposure to gunfire and street bombings before they left their homeland. For example, a participant stated she was healthy until a street bomb exploded and rendered her with physical deformity. She said, ‘‘I have burns on both my legs and my face because of the war…I left for safety.’’ Another said, about being healthy, ‘‘I am very concerned with safety…it [safety] is the most important thing.’’ In the homeland of Iraq, many women and children were targeted for murder or kidnapping. They were at risk for violence, rape, and harassment by civilians and armed groups. Many people were murdered and kidnapped for money exchange and revenge such as family members who served in the previous (collapsed) regimen, friends and neighbors, physicians and scientists with high reputations, wealthy people, and highly qualified professionals in the country. Most parents were reluctant to send their children to school for fear of kidnapping. Women struggled to take care of their children after their husbands fled to survive. They suffered from a lack of food, access to clean water, and health care [4]. During the period of displacement, many Iraqi refugees who stayed in the neighboring countries waiting for resettlement felt physically safe but lived in desperate need of basic life needs. Challenges included the ongoing fear of visa expiration and deportation. They experienced the inability to find work due to the lack of legal status. Finding shelter and accessing health care were major issues. In addition, their children were not able to attend school.
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Description of Health and Health Status in the Context of Resettlement The women described their health and health status in the context of resettlement as experiencing poor physical and mental health. Their status as refugees was considered to be a stigma to them. They described the unexpected challenges related to the process of resettlement and encounters with the health care system in the United States. In addition, they expressed fear and feelings of helplessness related to not finding a job; and the sense of loss and grieving related to fleeing their homeland and leaving loved ones and material possessions behind. Poor Physical and Mental Health In the process of the interviews, the majority of women complained of poor physical health, anxiety, stomach pain, psychological discomfort, thyroid disease, chronic disease, and other physical and psychological health issues. Several women expressed the belief that aging is associated with health deterioration. One said, ‘‘Physically, my body is healthy, mentally—no… Yes, I cry more nowadays and get upset more. Sometimes I yell at my children out of frustration… Health means everything to me because I lost it.’’ One participant, who left Iraq 4 years ago, arrived to the United States 2 years ago, and suffered from physical and psychological problems stated, ‘‘I have no health; every power in me is gone, where is the power I had? I can’t even open a jar.’’ Another stated ‘‘My psychological health was bad, and it affected my physical health…especially in Baghdad when I would worry about my husband and sons.’’ The Stigma of the Label ‘‘refugee’’ The status of ‘‘being a refugee’’ was not well-received by the women. Despite the severity of circumstances they experienced, the resettlement experience was both bitter and sweet. Participants voiced that they had fled from violence in Iraq, which they had never before seen or experienced. They fled their homeland seeking safety and security. About half of the participants stated that being labeled ‘‘refugee’’ was irritating. A participant summed up the feeling, ‘‘I don’t like to be a ‘‘refugee’’ …It is hard to accept it.’’ They described the word ‘‘refugee’’ as meaning helpless, dependent, lonely, and vigilant. Unexpected challenges encountered during the resettlement process. There were challenges that the women faced when they decided to come to the United States, including a different culture, religion, and belief system; a new life; and an unclear future. One participant said, ‘‘You begin a new life. Before, you had a job; you had your family, relatives, and friends.’’ Another stated that, ‘‘In Iraq, our
children were in different places, everybody was separated, my husband was threatened several times, and even my son had a gun pointed to his head…. Everything put a strain on my psychological health…despite all of that, when we fled to Syria it was heartbreaking.’’ She went on to say, ‘‘You know, if I had a chance to make the decision again, I wouldn’t do it.’’ All participants expressed their ‘‘new’’ concerns when they came to the United States. These included language, religion, culture, environment, jobs, lack of a support system, loneliness, and facing the unexpected. A participant and her family recognized these concerns before they left but had no choice but to leave. She said, ‘‘There were some things (in the Middle East) we didn’t have to worry about, like religion, tradition, and language. Here, these things affect our lives.’’ Another said, ‘‘You begin a new life.’’ Another said, ‘‘We knew everything there [Iraq], it was our home country…we were [in the United States] among strangers.’’ Unexpected Differences in Health Systems The Iraqi health system is a national health system in which every citizen is entitled to receive free health care. People accustomed to this type of system are not familiar with concepts related to health insurance, primary care physicians, long waiting in the emergency room, obtaining medicine without physician prescriptions, and calling to schedule appointments. When the participants were asked about their health experience in the United States, they expressed their lack of knowledge about the health care delivery system. The majority of women noted that the health care system is very complicated; language and communication were a big concern, as well as lack of trust in the health provider. A study participant explained, ‘‘When somebody gets sick you have to make an appointment with the doctor. What is the value of this appointment 2 weeks later than when you actually need it? This is a problem here, and we did not know this. Even for an emergency, you wait at least 3 h until you are seen. At times, you can go to the doctor, and they won’t give you medicine even though you are sick. At most, they will tell you to take over-the-counter medicine. For the kids, this is a problem because they do not deal well with pain.’’ Regarding communication with the health providers, another stated, ‘‘We believe that the American people [healthcare providers] have a high education, if they just explain to us about our problems.’’ Fear and Helplessness Related to Lack of Jobs The participants expressed the feeling of fear and worries related to being without jobs, losing state support (financial
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and health insurance), starting new life, fear of health deterioration with getting older. One participant said, ‘‘Lack of jobs…I had an excellent position [in Iraq]. I have a wealth of experience, but I cannot use it here.’’ Another stated, ‘‘…I am here alone without my parents, and I have a very bad job…maybe at any time I can lose it, ya know.’’ Loss, Grieving, and Feeling Guilty Refugees left loved ones, belongings, and home behind. They experienced loss, grieving, and feeling guilt for leaving others behind. A participant said, ‘‘I will never forget my neighbors and my closest friends. Also, when we had to sell the house that we lived in, it’s like we were pulled from our roots. This really affected me psychologically. However, at the same time I was optimistic about having a better future.’’ Another woman left her daughters in Syria because they are married and had families said, ‘‘I left my girls in Syria; how can I live here and my girls are far away from me? I cannot focus; this is what keeps making me sick. I am haunted by the images from Iraq and the separation from my daughters… it bothers me a lot.’’ Another said that she cannot forget the image of her 9-yearold brother, who was kidnapped in 2006. Among the participants were women who had well-paid jobs, such as teaching, engineering, administration, counseling, and others. One of the participants said that she owned an engineering company and loved her job. She had to leave everything because her husband’s life was threatened. Women were pushed to jeopardize their health and reputation to provide basic life survival for their families. The women felt frustrated and discouraged because they were unable to find jobs after they settled in the United States. Since many of the refugees had to remain 2–3 years in neighboring countries before leaving for the United States, many spent their entire life savings during this time in order to survive.
Discussion The Iraqi women refugees described the concepts of health slightly different than the Western descriptions found in the literature. The women described health within the context of ‘‘collective being well and healthy’’ rather than ‘‘individualistic being well and healthy.’’ The description of health may be derived from the women’s cultural expectations of their roles as primary family care takers and religious beliefs and values. This may be in contrast to the Western view which tends to be more individualistic [20]. The women did not perceive that they were physically, mentally, socially, economically, and spiritually healthy unless they could recognize the harmony and wellness
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within their families. The women in this study attributed poor physical and mental health to their constant fear and worries about their husbands, children, and loved ones. All participants valued health, and considered it as a ‘‘gift from God’’. Being healthy meant to them the ability to function inside and outside their homes within the culturally expected roles (mothers, wives, and sisters), as well as the absence of visible physical illnesses. Following religious traditions such as prayers was the mean to obtain the gift (health) from God (Almighty Allah). These findings were consistent with other findings from a study related to Arab-American immigrants and their knowledge, and attitudes and beliefs about cancer [21]. Praying and using religion for strength was also consistent with the findings of the refugee literature and Sudanese refugees [22]. The unique finding was that women described that safety and security are important components of health. This is important findings, refugee population went through physical and mental violence which violate their safety and security and disrupt their life stability. The other surprising finding was being called as refugees; this concept was undesirable for all women who were interviewed. They felt that they were labeled because of what they experienced in their homeland. Experiencing loss and grieving during the process of resettlement was consistent with findings in studies of other refugee populations [11, 22]. Post-traumatic stress disorder is reported to be about ten times higher among refugees who travel from the East to the West and resettle in Western countries than that of the general population in the homeland [23]. The psychosocial impact of the refugee experience is associated with the tragic and devastating consequences in terms of loss of loved ones, social support, fear, stress, anxiety, and financial deprivation. Study participants identified the challenges associated with accessing the health care system in the United States. Communication and language barriers were mentioned frequently during the interviews. These findings are consistent with the literature. That is, the language barrier among Arab Americans is the most significant barrier even for those who lived in the United States for many years and were able to speak English [21]. Consistent with other studies of refugee populations, study participants expressed their preference of receiving their health care from health care providers who understood their language and culture [11, 21]. Similar to findings in a study of Russian refugees in this same region [11], the participants in this study reported that they were unfamiliar with the health insurance systems, long waiting periods to see a health care provider, scheduling appointments and getting prescriptions from licensed physicians. In their homeland, medications such as antibiotics can easily be obtained either from over-the-counter or by pharmacists.
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Limitations
References
The interviews took place in the homes of the study participants. As a result, it was difficult to control the presence of children and other family members at times even when the women originally stated that they would be alone for the interview. As noted in a study with Sudanese refugees [22], the inability to interview the women alone may have resulted in the women not sharing experiences of torture and rape. This was a small sample size of Iraqi refugee women who, due to war in their homeland, resettled between 2003 and 2010 in an urban city in Eastern United States. The findings of this study cannot be generalized to other populations. Despite the above mentioned limitations, we believe that this study is unique in terms of the focused topic, population characteristics, and their experiences. To our knowledge, this topic has never been explored for this population (Iraqi refugee women) in the US or other hosting countries.
1. Devi S. Meeting the health needs of Iraqi refugees in Jordan. Lancet. 2007;370:1979–80. 2. Iraqi refugees processing fact sheet. U.S. Citizenship and Immigration Services. Retrieved on March 25th, 2014 from http://www. uscis.gov/humanitarian/refugees-asylum/refugees/iraqi-refugeeprocessing-fact-sheet; 2013. 3. Gibbings S: Women, peace and security 2004. Canadian Research Institute for the Advancement of Women 2004; 16. 4. Women’s Commission for Refugee Women and Children. (2008). Retrieved from http://www.rhrc.org. 5. Refugee law and legal definitions. (2013). Retrieved from http:// www.definitions.uslegal.com. 6. Aday LA. The health and health care needs of vulnerable populations in the United States. In: Anderson RM, editor. At risk in America. California: Jossey-Bass; 2001. p. 1–15. 7. Murray RB, Zentner JP. Health promotion strategies through the life span. New Jersey: Prentice Hall; 2001. 8. Pender N, Murdaugh C, Parsons MA. Health promotion in nursing practice. 6th ed. New Jersey: Pearson; 2006. 9. Dubos R, New Haven CT. Man adapting. Can J Public Health. 1965;50(11):447–57. 10. Schaefer K, Pond JB. Levine’s conservation model: a framework for nursing practice. Pennsylvania: F A Davis Company; 1991. 11. Resick LK. The meaning of health among midlife Russianspeaking women. J Nurs Scholarsh. 2008;40(3):248–53. 12. Aroian KJ, Khatutsky G, Tran TV, Balsam AL. Health and social service utilization among elderly immigrants from the former Soviet Union. J Nurs Scholarsh. 2001;33(3):265–71. 13. Lindgren T, Lipson J. Finding a way: Afghan women’s experience in community participation. J Transcult Nurs. 2004;15(2):122–30. 14. Burns N, Grove SK. Understanding nursing research: Building an evidence-based practice. Pennsylvania: Saunders; 2010. 15. Refugee arrival data. Office of Refugee Resettlement. (2012). Retrieved on March 20, 2014 from http://www.acf.hhs.gov/pro grams/orr/resource/refugee-arrival-data. 16. Polit DF, Beck CT. Nursing research: generating and assessing evidence for nursing practice. 8th ed. Pennsylvania: Lippincott; 2007. 17. Barritt L, Beekman T, Bleeker H, Mulderij K. Analyzing phenomenological descriptions. Phenomenol Pedagogy. 1984;2(1):1–17. 18. Beck CT. Critiquing qualitative research. Assoc Perioper Regist Nurs. 2009;90(4):543–54. 19. Le Vasseur JG. The problem of bracketing in phenomenology. Qual Res. 2003;13(3):408–20. 20. Arnold EC, Boggs KU. Interpersonal relationships. Professional Communication Skill for Nurses. 5th ed. Missouri: SaundersElevier; 2007. 21. Shah SM, Ayash C, Pharaon NF, Gany FM. Arab American immigrants in New York: health care and cancer knowledge, attitudes, and beliefs. J Immigr Minor Health. 2008;10:429–36. 22. Khawaja NG, White KM, Schweitzer R, Greenslade JH. Difficulties and coping strategies of Sudanese refugees: a qualitative approach. Transcult Psychiatry. 2008;45(3):489–512. 23. Fazel M. Prevalence of serious mental disorder in 7,000 refugees resettled in western countries: a systemic review. Lancet. 2005;365:1309–14.
Implications Health care providers need to be aware of the unique history experienced by refugee populations. Our findings support the importance of a multidisciplinary approach to health assessment that addresses social, cultural and religious values, past experiences, adjustment status, acceptance of being a refugee, and length of time in the United States. For the Iraqi refugee population, lack of knowledge related to the health care system in the United States can represent a new challenge in addition to cultural and religious values to access the health care services and contribute to health disparities in the United States. Further studies are necessary to shed light on the challenges and expectations of refugee women of different religions and beliefs during the resettlement process. Qualitative studies such as this one are a fundamental step for future intervention studies which focus on the elimination of health disparities among vulnerable refugee populations. Acknowledgments This study was funded by Epsilon Phi Chapter, Sigma Theta Tau International Honor Society of Nursing Conflict of interest The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
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ORIGINAL PAPER
The Description of Health Among Iraqi Refugee Women in the United States Khlood F. Salman • Lenore K. Resick
Springer Science+Business Media New York 2014
Abstract The purpose of this study was to understand the description of health among Iraqi women refugees, their health status, and health experiences during resettlement in the United States. Twelve women, ages 21–67 years old, who resettled in the United States during or after 2003 where interviewed. The women described health as a gift determined by God, the ability to function, the absence of physical symptoms, and the need to feel safe and secure in the context of resettlement. Although the Iraqi women valued health, during the resettlement process, seeking safety and feeling secure were the foremost priorities. Findings revealed that this is a vulnerable population which has experienced the violence of war and, as a result, have unique physical, mental, economic, and social concerns related to health. Implications are for a multidisciplinary approach to best meet the unique individual health needs of this vulnerable population. Keywords Health Iraqi refugee Women Vulnerable populations War
Introduction Since 2003, more than 4.5 million Iraqis have fled their homeland because of violence in Iraq. Some were displaced internally, and others fled to neighboring countries such as Jordan, Syria, and Egypt. Estimates are that at least 2,000 people became homeless daily from 2003 to 2007, which is reported to be the largest Middle East refugee K. F. Salman (&) L. K. Resick Duquesne University School of Nursing, 600 Forbes Avenue, Pittsburgh, PA 15282, USA e-mail: [email protected]
crisis in history [1]. In the United States (US), the number of Iraqi refugees seeking resettlement also has increased significantly since 2007. Based on the data reported by the U.S. Citizenship and Immigration Services (2013), the number of Iraqi refugees admitted to the United States was increased from 1,608 in 2007 to 18,016 in 2010 [2]. Approximately 52,285 Iraqis with refugee status have admitted to the United States between 2007 and 2010 [2]. The Canadian Research Institute for the Advancement of Women (CRIAW) reported that on average 75–80 % of displaced people in any crisis are women and children [3]. According to the Iraqi Red Crescent Society, more than 83 % of Iraqi refugees were women and children [4]. The term refugee refers to ‘‘a person who is unable or unwilling to return to their country of nationality because of persecution or a well-founded fear of persecution on account of race, religion, nationality, political opinions, or membership in a particular group’’ [5]. Refugee women have been identified as a vulnerable population at risk for physical and mental illnesses [6]. This study evolved out of our encounters with Iraqi refugee Muslim women who experienced critical life situations (e.g. wars and violence), who may have descriptions and perspectives of the concept of health that are different from the concept and perceptions of health outside of their homeland. Many of the Muslim women we encountered expressed reservations when coming to the United States related to religion and culture. These reservations include the traditional Islamic attire which makes them visually different than other women, language barriers, cultural norms and values. Understanding the description of health by the women from their own worldview is a fundamental step to ensure mutual understanding and effective communication which are the means for delivering culturally competent care.
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Background
Recruitment and Data Collection
Health care providers, strive constantly to achieve their clients’ ultimate goal of ‘‘being healthy.’’ The concept of health is evolving with multidimensional descriptions. There is no one standard description of the concept of health. Health has been described as, ‘‘a state of well-being in which a person is able to use purposeful, adaptive responses and processes physically, emotionally, spiritually and socially’’ [7] (p. 53). Other scholars have described health as, ‘‘actualization of inherent and acquired human potential through goal-directed behavior, competent selfcare, and satisfying relationship with others’’ [8] (p. 22). Attaining high levels of health has been described as a state when the person is ‘‘free of discomfort and pain that permits one to function effectively within the environment’’ [8] (p. 19). The meaning of health has been described in terms of stability and balance—the ability to adapt to the environment and to adjust to different internal or external stresses [9, 10]. The literature revealed limited studies related to the description of health by immigrant and refugee populations. Although studies have addressed the health status and meaning of health among Russian refugee women [11, 12] and Afghanistan refugee women living in the United States [13], no single study focused on the description of health and the health status of Muslim Iraqi women refugees after the Iraqi war crisis in 2003 within the context of resettlement. The purpose of this study was to answer the following questions: (1) How do Iraqi refugee women describe the concept of health and ‘‘being healthy?’’; (2) How do Iraqi refugee women describe their own health status within the context of resettlement?; (3) How do Iraqi refugee women describe their health experiences within the context of resettlement?
The study was conducted in a city located in the eastern part of the United States. The city was chosen because of the large number of Iraqi refugees who have recently settled in this area. Data from the Office of Refugee resettlement reported that the number of Iraqi refugees who arrived in the state where this study took place had increased more than ten times from 40 in 2003 to 479 in 2010 [15]. In the specific region of this study, most of the Iraqi refugees were self-identified as Muslim women. The study was approved by the Institutional Review Board (IRB) for protection of human subjects. Study participants were recruited through flyers in both English and the Arabic languages. The flyers were posted in the local Islamic Center and two agencies serving refugee populations. Women were also recruited through word of mouth and key informants. Key informants were immigrant Muslim women from the Middle East, who had been in the United States for many years, and are known for their volunteer services to the Muslim community at large. The participants were selected using purposive sampling and snowballing technique [16]. The study participants were asked to identify and refer women who met the criteria for the study. The participants were recruited from a potential pool of approximately 40 women. Twelve women participated in this study. Once we determined the eligible study participants, a time and place were scheduled for the initial meeting at the convenience of the participant. All interviews were conducted in a natural setting in the women’s homes. Study participants were self-identified as Iraqi women refugees who resettled in the United States during or after 2003, were 21 years or older, spoke either Arabic and/or English, were able, and open to discuss elements of their health experiences within the context of being a refugee. Data Collection
Method A qualitative descriptive inquiry approach was used to collect data. Descriptive research is described as ‘‘the exploration and description of phenomena in a real-life situation. It provides an accurate account of characteristics of particular individuals, situations or groups’’ [14] (p. 34). The purpose of the descriptive design is to describe the phenomenon in a holistic way, as it is experienced. We sought to study the description of the concept of health, the health status as understood by the Iraqi women refugees, and their experiences within the context of the resettlement (i.e., real life situation). The descriptive qualitative design was consistent with the purpose of this study and the research questions.
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The interviews were completed within a 5-month period (June 2010 to November 2010). When data collection began, we repeated the explanation of the study and asked the participant to read the informed consent document; the participant received a copy of the English or the Arabic consent document depending on their preference. We asked permission to tape the interview. Once permission was given, we asked questions about demographic data. The audiotaped interview directly followed the collection of demographic data. The participants were asked to describe the concept of health, what health meant to them, their health status and experiences within the context of resettlement. Probe questions were included to initiate responses and to assist in clarifying meanings. These questions
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included: ‘‘Can you tell me more about that?’’ and ‘‘Can you give me an example?’’ The interview ended with debriefing questions such as, ‘‘Is there anything else about health and resettlement that you think I should know?’’ and ‘‘I will be interviewing other women from Iraq about their refugee experience and health. What has this interview been like for you?’’ These were asked to allow study participants to discuss issues of importance that may not have been elicited through the original interview questions proposed in the study. Although it was anticipated that it would take 60–90 minutes to complete the interviews, no time limit was imposed. Most interviews took about an hour to complete. Data were collected until ‘‘saturation’’ was reached [16]. Saturation was reached when no new data emerged from the analysis of the transcriptions. Field notes were kept to describe the natural environment, in which the interviews took place, document the content of informal conversations that occurred spontaneously after the taped sessions were completed and to provide a context of the verbal and emotional expressions during the interviews. A second follow-up interview was scheduled approximately 2–3 weeks following the initial interview to clarify responses. However, two participants were unable to complete a second interview; one woman made a family emergency trip to Jordan and the other one left the United States due to the challenges experienced in learning the language and feeling overwhelmed throughout the resettlement process. To ensure accuracy of the initial analysis, we verified the interpretations of transcripts from the first interview during the second interview. Participants specifically were asked if they had anything to add to the points discussed and whether there was anything they would like to have omitted from the analysis. Changes, additions, and clarifications in regard to the researchers’ interpretation were discussed. The second interview continued until the informants agreed that the descriptions of their experiences had been interpreted as they had intended. The second interviews took approximately 45 minutes to an hour each to complete. Data Analysis An experienced transcriber, who signed a confidentiality statement, transcribed the audiotape interviews verbatim. The tapes in Arabic were translated to English and then translated back to Arabic by another translator to ensure conceptual equivalency. Then, to ensure accuracy, two different Arabic-speaking individuals translated the transcript back to English. We independently reviewed each transcript, assigned themes that reflected the words of the study participants as closely as possible, and clustered common themes [17]. Then we compared the independent coding; generally,
there was agreement between our independent coding. The themes that were identified and agreed upon served as the discussion topics during the second interview. We read aloud the identified themes and discussed them with participants to check the degree of participant and investigator agreement. Generally there was agreement. During the few times there was not agreement, the inconsistency was discussed until consensus was reached. The rigor and trustworthiness of the research process were ensured by addressing ‘‘credibility, confirmability, dependability, transferability, and authenticity’’ [18] (p. 544). Credibility was achieved by spending adequate time with the informants to identify repeated or reappearing patterns, and allowing adequate time for the participants to express their personal experiences and verbalize concerns. To avoid bias, we conducted the interviews together, and bracketed our assumptions and preconceived knowledge related to the interview questions by recording our responses to the interview questions before meeting with the study participants [19]. We completed data analysis independent of each other, and then compared results. Probe questions were also included to initiate responses and to assist in clarifying meanings. Transferability was addressed by ensuring that all the participants were self-identified as Iraqi women refugees, who have been the United States since 2003 and representative of this population. Dependability (or the consistency of findings) was achieved by collecting data until saturation was reached. All interviews were audio taped to enable us to listen multiple times for rechecking and ensuring consistency of interpretations. Confirmability was attended to by scheduling a second interview with the participants to confirm the interpretations of their experiences and description of the study phenomena. We also analyzed the data separately, compared the results, and discussed differences and similarities of the themes. Authenticity was achieved as we ensured the trustworthiness of the data. All interviews were conducted by the two of us. The principal investigator is native to the language and culture, and has been actively involved with the Iraqi refugee community for the past several years. We also hired a professional transcriber, who is fluent in English and Arabic languages to ensure additional accuracy. All audio-taped interviews were in the native language of the participants translated to English and back to Arabic and then to English.
Findings Demographics The average age of the 12 refugee women who participated in the study was 43 years of age with an age range from 21
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to 67 years. The length of stay in the United States ranged from 2 months to 4 years. Educational levels of the study participants varied from completion of middle school to a college degree. All women except for one (who was single) were married and lived with their spouses. The married women had two to six children ranging in age from 5 to 35 years of age.
Health as Experiencing No Physical Symptoms Women also described feeling healthy as having no visible disease and being healthy when they had no physical symptoms. For example, a participant stated that she was healthy saying, ‘‘I never went to the doctor. When I go to doctors, they are surprised at how well I am.’’ Health as Being Safe and Secure
Description of the Concept of Health Data analysis resulted in several themes related to the description of health. These included health as a highly valued treasure; a gift determined by God; the ability to function inside and outside the home in expected roles (e.g., wife, mother, sister, and student); experiencing no physical symptoms; and being safe and secure. Health as a Highly Valued Treasure One participant summed up the responses from the other participants, ‘‘Health means everything to me; without it I cannot be happy. Health is the most important thing… we consider it as the crown on the head of healthy people…it is like a treasure.’’
Health as a Gift Determined by God All the women expressed a strong belief in health as determined by God, and used prayers to help them in all aspects of life. ‘‘We say everything comes from God, you know, If God wants something wrong with us, nobody can stop it.’’ Another participant shared her experience of being diagnosed with a suspicious lesion in the breast after a mammogram screening. She mentioned that ‘‘she asked Allah (God) to help her in her prayers; days and nights, because she did not want that disease (cancer)’’. After she went for her second mammogram, the physician informed her that it was negative. Health as the ability to function inside and outside the home in expected roles. One participant’s words summed up the theme of health as the ability to function. ‘‘It means everything to me; health is involved in the way you take care of your family, how you live your life. If you’re healthy, you can fulfill all of the duties outside and inside the house.’’ Another stated, ‘‘I was happy, active, I didn’t have worries…Whenever I was healthy, I could go out, take care of the house, my kids. My movement in the house becomes easier. My duties within the house can be and are completed…uhhh… if my neighbors need help, I can help them also.’’ According to another participant, ‘‘If one doesn’t have good health….life stops.’’
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Although health was not a major focus for the women during the resettlement process, they all valued health, and considered safety and security as important aspects in the description of the health and ‘‘being healthy’’ status. A participant expressed that being unsafe with her family made her sick, ‘‘… we just wanted to be safe because our lives (both her husband’s and hers), my kid’s life, was in danger at that time…I was sick!’’ She was worried about her status, saying, ‘‘I hope that we will all be safe and secure… not worry about tomorrow because that’s what makes me sick…uhm, because, you know, we are not sure what will happen tomorrow…’’ Other participants also mentioned that safety was their highest priority. This is obviously due to the fact that many women and children were at risk for kidnapping, murder, and exposure to gunfire and street bombings before they left their homeland. For example, a participant stated she was healthy until a street bomb exploded and rendered her with physical deformity. She said, ‘‘I have burns on both my legs and my face because of the war…I left for safety.’’ Another said, about being healthy, ‘‘I am very concerned with safety…it [safety] is the most important thing.’’ In the homeland of Iraq, many women and children were targeted for murder or kidnapping. They were at risk for violence, rape, and harassment by civilians and armed groups. Many people were murdered and kidnapped for money exchange and revenge such as family members who served in the previous (collapsed) regimen, friends and neighbors, physicians and scientists with high reputations, wealthy people, and highly qualified professionals in the country. Most parents were reluctant to send their children to school for fear of kidnapping. Women struggled to take care of their children after their husbands fled to survive. They suffered from a lack of food, access to clean water, and health care [4]. During the period of displacement, many Iraqi refugees who stayed in the neighboring countries waiting for resettlement felt physically safe but lived in desperate need of basic life needs. Challenges included the ongoing fear of visa expiration and deportation. They experienced the inability to find work due to the lack of legal status. Finding shelter and accessing health care were major issues. In addition, their children were not able to attend school.
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Description of Health and Health Status in the Context of Resettlement The women described their health and health status in the context of resettlement as experiencing poor physical and mental health. Their status as refugees was considered to be a stigma to them. They described the unexpected challenges related to the process of resettlement and encounters with the health care system in the United States. In addition, they expressed fear and feelings of helplessness related to not finding a job; and the sense of loss and grieving related to fleeing their homeland and leaving loved ones and material possessions behind. Poor Physical and Mental Health In the process of the interviews, the majority of women complained of poor physical health, anxiety, stomach pain, psychological discomfort, thyroid disease, chronic disease, and other physical and psychological health issues. Several women expressed the belief that aging is associated with health deterioration. One said, ‘‘Physically, my body is healthy, mentally—no… Yes, I cry more nowadays and get upset more. Sometimes I yell at my children out of frustration… Health means everything to me because I lost it.’’ One participant, who left Iraq 4 years ago, arrived to the United States 2 years ago, and suffered from physical and psychological problems stated, ‘‘I have no health; every power in me is gone, where is the power I had? I can’t even open a jar.’’ Another stated ‘‘My psychological health was bad, and it affected my physical health…especially in Baghdad when I would worry about my husband and sons.’’ The Stigma of the Label ‘‘refugee’’ The status of ‘‘being a refugee’’ was not well-received by the women. Despite the severity of circumstances they experienced, the resettlement experience was both bitter and sweet. Participants voiced that they had fled from violence in Iraq, which they had never before seen or experienced. They fled their homeland seeking safety and security. About half of the participants stated that being labeled ‘‘refugee’’ was irritating. A participant summed up the feeling, ‘‘I don’t like to be a ‘‘refugee’’ …It is hard to accept it.’’ They described the word ‘‘refugee’’ as meaning helpless, dependent, lonely, and vigilant. Unexpected challenges encountered during the resettlement process. There were challenges that the women faced when they decided to come to the United States, including a different culture, religion, and belief system; a new life; and an unclear future. One participant said, ‘‘You begin a new life. Before, you had a job; you had your family, relatives, and friends.’’ Another stated that, ‘‘In Iraq, our
children were in different places, everybody was separated, my husband was threatened several times, and even my son had a gun pointed to his head…. Everything put a strain on my psychological health…despite all of that, when we fled to Syria it was heartbreaking.’’ She went on to say, ‘‘You know, if I had a chance to make the decision again, I wouldn’t do it.’’ All participants expressed their ‘‘new’’ concerns when they came to the United States. These included language, religion, culture, environment, jobs, lack of a support system, loneliness, and facing the unexpected. A participant and her family recognized these concerns before they left but had no choice but to leave. She said, ‘‘There were some things (in the Middle East) we didn’t have to worry about, like religion, tradition, and language. Here, these things affect our lives.’’ Another said, ‘‘You begin a new life.’’ Another said, ‘‘We knew everything there [Iraq], it was our home country…we were [in the United States] among strangers.’’ Unexpected Differences in Health Systems The Iraqi health system is a national health system in which every citizen is entitled to receive free health care. People accustomed to this type of system are not familiar with concepts related to health insurance, primary care physicians, long waiting in the emergency room, obtaining medicine without physician prescriptions, and calling to schedule appointments. When the participants were asked about their health experience in the United States, they expressed their lack of knowledge about the health care delivery system. The majority of women noted that the health care system is very complicated; language and communication were a big concern, as well as lack of trust in the health provider. A study participant explained, ‘‘When somebody gets sick you have to make an appointment with the doctor. What is the value of this appointment 2 weeks later than when you actually need it? This is a problem here, and we did not know this. Even for an emergency, you wait at least 3 h until you are seen. At times, you can go to the doctor, and they won’t give you medicine even though you are sick. At most, they will tell you to take over-the-counter medicine. For the kids, this is a problem because they do not deal well with pain.’’ Regarding communication with the health providers, another stated, ‘‘We believe that the American people [healthcare providers] have a high education, if they just explain to us about our problems.’’ Fear and Helplessness Related to Lack of Jobs The participants expressed the feeling of fear and worries related to being without jobs, losing state support (financial
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and health insurance), starting new life, fear of health deterioration with getting older. One participant said, ‘‘Lack of jobs…I had an excellent position [in Iraq]. I have a wealth of experience, but I cannot use it here.’’ Another stated, ‘‘…I am here alone without my parents, and I have a very bad job…maybe at any time I can lose it, ya know.’’ Loss, Grieving, and Feeling Guilty Refugees left loved ones, belongings, and home behind. They experienced loss, grieving, and feeling guilt for leaving others behind. A participant said, ‘‘I will never forget my neighbors and my closest friends. Also, when we had to sell the house that we lived in, it’s like we were pulled from our roots. This really affected me psychologically. However, at the same time I was optimistic about having a better future.’’ Another woman left her daughters in Syria because they are married and had families said, ‘‘I left my girls in Syria; how can I live here and my girls are far away from me? I cannot focus; this is what keeps making me sick. I am haunted by the images from Iraq and the separation from my daughters… it bothers me a lot.’’ Another said that she cannot forget the image of her 9-yearold brother, who was kidnapped in 2006. Among the participants were women who had well-paid jobs, such as teaching, engineering, administration, counseling, and others. One of the participants said that she owned an engineering company and loved her job. She had to leave everything because her husband’s life was threatened. Women were pushed to jeopardize their health and reputation to provide basic life survival for their families. The women felt frustrated and discouraged because they were unable to find jobs after they settled in the United States. Since many of the refugees had to remain 2–3 years in neighboring countries before leaving for the United States, many spent their entire life savings during this time in order to survive.
Discussion The Iraqi women refugees described the concepts of health slightly different than the Western descriptions found in the literature. The women described health within the context of ‘‘collective being well and healthy’’ rather than ‘‘individualistic being well and healthy.’’ The description of health may be derived from the women’s cultural expectations of their roles as primary family care takers and religious beliefs and values. This may be in contrast to the Western view which tends to be more individualistic [20]. The women did not perceive that they were physically, mentally, socially, economically, and spiritually healthy unless they could recognize the harmony and wellness
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within their families. The women in this study attributed poor physical and mental health to their constant fear and worries about their husbands, children, and loved ones. All participants valued health, and considered it as a ‘‘gift from God’’. Being healthy meant to them the ability to function inside and outside their homes within the culturally expected roles (mothers, wives, and sisters), as well as the absence of visible physical illnesses. Following religious traditions such as prayers was the mean to obtain the gift (health) from God (Almighty Allah). These findings were consistent with other findings from a study related to Arab-American immigrants and their knowledge, and attitudes and beliefs about cancer [21]. Praying and using religion for strength was also consistent with the findings of the refugee literature and Sudanese refugees [22]. The unique finding was that women described that safety and security are important components of health. This is important findings, refugee population went through physical and mental violence which violate their safety and security and disrupt their life stability. The other surprising finding was being called as refugees; this concept was undesirable for all women who were interviewed. They felt that they were labeled because of what they experienced in their homeland. Experiencing loss and grieving during the process of resettlement was consistent with findings in studies of other refugee populations [11, 22]. Post-traumatic stress disorder is reported to be about ten times higher among refugees who travel from the East to the West and resettle in Western countries than that of the general population in the homeland [23]. The psychosocial impact of the refugee experience is associated with the tragic and devastating consequences in terms of loss of loved ones, social support, fear, stress, anxiety, and financial deprivation. Study participants identified the challenges associated with accessing the health care system in the United States. Communication and language barriers were mentioned frequently during the interviews. These findings are consistent with the literature. That is, the language barrier among Arab Americans is the most significant barrier even for those who lived in the United States for many years and were able to speak English [21]. Consistent with other studies of refugee populations, study participants expressed their preference of receiving their health care from health care providers who understood their language and culture [11, 21]. Similar to findings in a study of Russian refugees in this same region [11], the participants in this study reported that they were unfamiliar with the health insurance systems, long waiting periods to see a health care provider, scheduling appointments and getting prescriptions from licensed physicians. In their homeland, medications such as antibiotics can easily be obtained either from over-the-counter or by pharmacists.
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Limitations
References
The interviews took place in the homes of the study participants. As a result, it was difficult to control the presence of children and other family members at times even when the women originally stated that they would be alone for the interview. As noted in a study with Sudanese refugees [22], the inability to interview the women alone may have resulted in the women not sharing experiences of torture and rape. This was a small sample size of Iraqi refugee women who, due to war in their homeland, resettled between 2003 and 2010 in an urban city in Eastern United States. The findings of this study cannot be generalized to other populations. Despite the above mentioned limitations, we believe that this study is unique in terms of the focused topic, population characteristics, and their experiences. To our knowledge, this topic has never been explored for this population (Iraqi refugee women) in the US or other hosting countries.
1. Devi S. Meeting the health needs of Iraqi refugees in Jordan. Lancet. 2007;370:1979–80. 2. Iraqi refugees processing fact sheet. U.S. Citizenship and Immigration Services. Retrieved on March 25th, 2014 from http://www. uscis.gov/humanitarian/refugees-asylum/refugees/iraqi-refugeeprocessing-fact-sheet; 2013. 3. Gibbings S: Women, peace and security 2004. Canadian Research Institute for the Advancement of Women 2004; 16. 4. Women’s Commission for Refugee Women and Children. (2008). Retrieved from http://www.rhrc.org. 5. Refugee law and legal definitions. (2013). Retrieved from http:// www.definitions.uslegal.com. 6. Aday LA. The health and health care needs of vulnerable populations in the United States. In: Anderson RM, editor. At risk in America. California: Jossey-Bass; 2001. p. 1–15. 7. Murray RB, Zentner JP. Health promotion strategies through the life span. New Jersey: Prentice Hall; 2001. 8. Pender N, Murdaugh C, Parsons MA. Health promotion in nursing practice. 6th ed. New Jersey: Pearson; 2006. 9. Dubos R, New Haven CT. Man adapting. Can J Public Health. 1965;50(11):447–57. 10. Schaefer K, Pond JB. Levine’s conservation model: a framework for nursing practice. Pennsylvania: F A Davis Company; 1991. 11. Resick LK. The meaning of health among midlife Russianspeaking women. J Nurs Scholarsh. 2008;40(3):248–53. 12. Aroian KJ, Khatutsky G, Tran TV, Balsam AL. Health and social service utilization among elderly immigrants from the former Soviet Union. J Nurs Scholarsh. 2001;33(3):265–71. 13. Lindgren T, Lipson J. Finding a way: Afghan women’s experience in community participation. J Transcult Nurs. 2004;15(2):122–30. 14. Burns N, Grove SK. Understanding nursing research: Building an evidence-based practice. Pennsylvania: Saunders; 2010. 15. Refugee arrival data. Office of Refugee Resettlement. (2012). Retrieved on March 20, 2014 from http://www.acf.hhs.gov/pro grams/orr/resource/refugee-arrival-data. 16. Polit DF, Beck CT. Nursing research: generating and assessing evidence for nursing practice. 8th ed. Pennsylvania: Lippincott; 2007. 17. Barritt L, Beekman T, Bleeker H, Mulderij K. Analyzing phenomenological descriptions. Phenomenol Pedagogy. 1984;2(1):1–17. 18. Beck CT. Critiquing qualitative research. Assoc Perioper Regist Nurs. 2009;90(4):543–54. 19. Le Vasseur JG. The problem of bracketing in phenomenology. Qual Res. 2003;13(3):408–20. 20. Arnold EC, Boggs KU. Interpersonal relationships. Professional Communication Skill for Nurses. 5th ed. Missouri: SaundersElevier; 2007. 21. Shah SM, Ayash C, Pharaon NF, Gany FM. Arab American immigrants in New York: health care and cancer knowledge, attitudes, and beliefs. J Immigr Minor Health. 2008;10:429–36. 22. Khawaja NG, White KM, Schweitzer R, Greenslade JH. Difficulties and coping strategies of Sudanese refugees: a qualitative approach. Transcult Psychiatry. 2008;45(3):489–512. 23. Fazel M. Prevalence of serious mental disorder in 7,000 refugees resettled in western countries: a systemic review. Lancet. 2005;365:1309–14.
Implications Health care providers need to be aware of the unique history experienced by refugee populations. Our findings support the importance of a multidisciplinary approach to health assessment that addresses social, cultural and religious values, past experiences, adjustment status, acceptance of being a refugee, and length of time in the United States. For the Iraqi refugee population, lack of knowledge related to the health care system in the United States can represent a new challenge in addition to cultural and religious values to access the health care services and contribute to health disparities in the United States. Further studies are necessary to shed light on the challenges and expectations of refugee women of different religions and beliefs during the resettlement process. Qualitative studies such as this one are a fundamental step for future intervention studies which focus on the elimination of health disparities among vulnerable refugee populations. Acknowledgments This study was funded by Epsilon Phi Chapter, Sigma Theta Tau International Honor Society of Nursing Conflict of interest The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
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